A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?
“You shouldn’t feel any pain since the local area is anesthetized.”
“Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.”
“Most clients report more discomfort from the preparation than from the procedure itself.”
“You may feel some cramping during the procedure.”
The Correct Answer is D
Choice A: “You shouldn’t feel any pain since the local area is anaesthetized.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client that they will not feel any pain, as this may create unrealistic expectations and increase anxiety if they do experience discomfort. The nurse should also not tell the client that the local area is anaesthetized, as this is not true. The client does not receive local anesthesia for a colonoscopy, but rather sedation and pain medication.
Choice B: “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client not to worry, as this may sound dismissive and insensitive to their concerns. The nurse should also not tell the client that they will not remember anything about the procedure, as this is not true. The client may receive conscious sedation for a colonoscopy, which means that they are awake but drowsy and relaxed. They may have some memory loss of the procedure, but they are not completely unconscious.
Choice C: “Most clients report more discomfort from the preparation than from the procedure itself.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not compare the client’s experience to other clients, as this may minimize their feelings and individual differences. The nurse should also not focus on the preparation, which involves drinking a large amount of liquid laxative to empty the colon, as this may increase anxiety and dread for the client. The nurse should instead focus on providing information and support for both the preparation and the procedure.
Choice D: “You may feel some cramping during the procedure.” This is a response that the nurse should make to the client who is scheduled for a colonoscopy, which is a diagnostic test that uses a flexible tube with a camera to examine the colon and rectum. The nurse should inform the client that they may feel some cramping during the procedure as the tube is inserted and moved through the colon. The nurse should also reassure the client that they will receive sedation and pain medication to make them comfortable and relaxed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.
Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.
Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.
Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.
Correct Answer is A
Explanation
Choice A: Determine the client’s calcium level. This is the priority action for the nurse to take because the client might have hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia can occur after a thyroidectomy due to accidental removal or damage of the parathyroid glands, which regulate calcium levels. Hypocalcemia can cause muscle spasms, tetany, paresthesia, and seizures.
Choice B: Give the client an oral potassium supplement. This is not an appropriate action for the nurse to take because the client might have hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can also occur after a thyroidectomy due to damage to the adrenal glands, which regulate potassium levels. Hyperkalemia can cause muscle weakness, arrhythmias, and cardiac arrest.
Choice C: Administer intravenous normal saline solution. This is not a necessary action for the nurse to take because the client does not have signs of dehydration or fluid imbalance. Normal saline solution does not affect calcium or potassium levels.
Choice D: Monitor the client’s peripheral pulses. This is an important action for the nurse to take, but not the priority. The nurse should monitor the client’s peripheral pulses for signs of decreased perfusion or ischemia, which can result from hypocalcemia or hyperkalemia affecting the cardiac function. However, this should be done after determining the client’s calcium level and correcting it if needed.
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